I am now reading a terrific book by a New York psychotherapist, Gary Greenberg, entitled The Book of Woe which is about the writing and publication of the DSM, the Diagnostic Statistical Manual. The DSM is the official handbook of the American Psychiatric Association and has long been the standard guide for mainstream psychiatry. I won't say much more about Greenberg's book now as I need to finish reading it first and may want to write a formal review of it later. But suffice it to say that the book belongs on the same shelf as Robert Whitaker's Anatomy of an Epidemic and Richard Bentall's Doctoring the Mind, both of which present scathing critiques of contemporary psychiatric theory and practice. It seems, in fact, that there is something of a backlash against psychiatry these days which would resemble anti-psychiatry some forty odd years ago were it not for the more temperate and cautious style of argument of psychiatry's more recent critics (Bentall, in fact, calls his approach rational anti-psychiatry to distinguish it from the wilder pronouncements of people like Laing, Esterson and Cooper). Even so, there is one important point which would seem to unite the old renegades of anti-psychiatry and the new critics of contemporary psychiatry. Both the old radicals and the new iconoclasts doubt the medical reality of what is thoughtlessly and perhaps misleadingly called mental illness.
The Myth of Mental Illness, was a highly influential tract published in 1961 by Thomas Szasz, an American psychiatrist who, though often called an anti-psychiatrist, vigorously denied any association with that band of radicals. Nevertheless, his argument that to confuse the emotional difficulties that people face (which he called "problems in living") with any sort of real medical condition was a grave category error which carried great critical force for the radicals of the Sixties. It would seem it still does so today. But, needless to say, mainstream psychiatry has never had any patience with this line of argument. Ever since the 1970's and the publication of the third edition of the DSM, psychiatry has become increasingly committed to strictly biological models of mental illness which make few, if any concessions to the subjectivity of psychiatric patients. Indeed, Emil Kraeplin, the father of modern psychiatry, declared that psychiatrists should have no more empathy for their patients than surgeons should have for theirs. Unfortunately, psychiatry's attempt to treat mental illnesses as pathologies like any other has been a tremendous failure as the dramatic rise in the incidence of mental illness since the 1970's clearly shows.
But if what we call mental illness is no such thing, what exactly is this form of suffering whose reality can hardly be doubted? Here I think the new critics of psychiatry have much more insightful things to say than the old anti-psychiatrists who were often intemperate, if not fanatical in attacking psychiatric and societal norms. When Cooper, for example, called for the death of the family, you had the feeling that he wanted the gallows to be prepared for Mum and Dad. By contrast, the new critics offer a careful appraisal of medical evidence to demonstrate that the current psychiatric models of mental illness simply do not work and often lead to treatments that make patients much worse than they were before. Bentall, a clinical psychologist, offers a fairly good, if provisional, alternative model of mental illness in his book, Madness Explained. But if anything, I am more impressed by Greenberg's frank admission of being baffled by mental illness, especially in some of its more florid manifestations. I think the inference to be drawn here is that though madness is certainly like an illness in the suffering it causes, it is not an actual illness in either its causes or its treatment.
The Buddha, it should be noted, held no Szaszian doubts about the reality of mental illness. But unlike Kraeplin and his descendants in modern psychiatry, he did not think its cause was any physical disorder, either. Moreover, of the two types of illness, physical and mental, he regarded mental illness as much worse. For the worst that can ensue from any physical illness is death, whereas any mental illness is certain to lead to an unfavourable rebirth, most likely in a hell or animal realm. But at this point we may be tempted to regard the Buddha's use of the term mental illness as little more than a metaphysical conceit. But was it? According to Buddhism, the roots of any mental illness are the three passions of aversion, greed and delusion, which are referred to as either fires or poisons. These three passions are almost always active in some way or another in the mentality of virtually all living beings. Indeed, these passions drive the round of rebirth as they perpetuate craving. Seen from a Buddhist perspective, then, we are almost all mentally ill, at least some of the time. But then it may be hard to see how such an idea of mental illness, which appears all too inclusive, could be relevant to any modern concept of mental illness, especially when the only cure for rebirth is nirvana.
Yet, aversion, greed and delusion almost always lie behind the complaints that bring people into psychotherapy. Aversion and greed feed psychological frustrations like wood on a fire. And delusion is universally regarded as a symptom of mental illness, though Buddhism would not confine its understanding of delusion to any clinical definition. According to Buddhism, we are all deluded to some extent, which means that we all misapprehend reality because of the distorted perceptions that our cravings impose on our view of things. Personally, I have always preferred to view the passions of aversion, greed and delusion as poisons, even though the original metaphor used in the Pali Canon referred to them as fires. But as a therapist I often reflect on how apt it is to see them as real poisons whose effects can be literally poisonous. Anybody who has ever worked as a counsellor or therapist probably has had clients who suffered their aversive anger in waves of bile that may have caused actual nausea. And greed often expresses itself as muscular tension that feels like a compressed spring of unfulfilled yearning. The poisonous effects of delusion, however, are seldom so apparent, which makes it the hardest passion to detect, as well as the most insidious poison to treat. Indeed, once identified, anger and greed can usually be dealt with. But aversion and greed usually lie concealed beneath a veil of delusion which is experienced as self. Anyway, the point I am making is that we have something here that is far more practical in dealing with mental illness than a mere metaphysical conceit.
When Buddhism states that everyone is mentally ill, it also goes on to assert that the Eight Fold path is the course of treatment that each individual must undertake in order to be cured. But mental illness as it is more commonly understood may present greater hazards on the Buddhist path that most other people don't have to face. This is where psychotherapy can help those who suffer mental illness acquire the resources to live more purposively, perhaps even to embark on the Buddhist path. Does this mean that Buddhist psychotherapy is better than any other forms of psychotherapy? Not necessarily. For success in therapy is largely the result of a good therapeutic alliance in which the theoretical orientation of the therapist seems to count for comparatively little. But perhaps even more importantly, a psychotherapist is not a confessor or spiritual guide. For a spiritual guide works within a particular spiritual paradigm to bring an aspirant to spiritual truth; a therapist works from a therapeutic orientation to reach the client in his or her life situation, but without imposing any spiritual agenda.
But to get back to the original question of this blog: is mental illness just a myth? Maybe; maybe not. The debate is far from settled. But aversion, greed and delusion are not myths at all. They make the world go around. And sometimes they move people to take up psychotherapy.